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7 Cards in this Set

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Intro to Drug Therapy

Nursing Process:



Assessment, nursing problem, planning, implementation, evaluation

Assessment

Data from various sources( patient, family, caregiver, medical record) collected thru interview direct and indirect questioning, observation, head to toe assessment, medical record review. Subjective and objective data6 elements to include

6 elements to include when getting a medication order:



•Pt name


•Date the order was written


•Name of drug


•Drug dose amount and frequency


•route of administration


•prescribers signature

Nursing dx is formed using NANDA

6 rights to be checked 3 times before giving meds:

•right drug- check against label for appropriateness


•right dose- watch decimal points and zeros


•right time- 30 minutes before or after actual time, except STAT


•right route- never assume


•right pt- 2 identifiers. Name and birthday...allergies


•right documentation- crucial to pt safety

Med errors

A major problem in healthcare

Charting Don'ts

Don't record staffing problems


Don't use negative language


Don't use abbreviations


Don't chart anything but facts


Don't mention incident report in charting


Don't use casual conversations

High alert meds

Heparin, insulin, chemo meds